Microsurgical Management of a Middle Cranial Fossa Dural Arteriovenous Fistula After Failed Embolization: 2-Dimensional Operative Video.

Dural arteriovenous fistulas (DAVFs) are intracranial vascular lesions with abnormal communication between the dural arteries and dural and/or cortical venous systems. While benign DAVFs, like Cognard I and IIa/Borden I, can be observed, higher-grade DAVFs, such as Cognard IIb-V/Borden II and III, should be treated.1,2 This video article depicts the microsurgical management after embolization of a middle cranial fossa Cognard IV DAVF with venous varices causing mass effect in the right thalamus, basal ganglia, and posterior limb of the right internal capsule. Initial attempts at embolization showed persistent arterial supply from the right ophthalmic artery and distal right internal maxillary artery, with sustaining cortical venous reflux. Microsurgical clipping was chosen because of venous congestion, associated risk of hemorrhage, and corresponding neurological symptoms. The patient consented to the procedure. Intraoperative angiography revealed successful obliteration of the fistula, and postoperative imaging displayed no residual DAVF and thrombosed venous varices without complications. The patient showed remarkable improvement, with a resolution of neurological deficits on discharge to rehabilitation. This case highlights the potential efficacy of direct clipping after unsuccessful endovascular intervention for DAVFs. Understanding the angioarchitecture with identification of the fistulous point, using intraoperative imaging modalities, and ensuring comprehensive exposure are crucial steps in such microsurgical interventions.